The blue Rhino of pain

[VentdependenT]

nothing like seeing a vigorous bubbling stream of venous blood pouring out of your perc trach incision to wake you up.

I will NOT be doing these in the community. Gen surg or ENT can have em.

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[bigtuna]

venous bleeders aren't usually a problem - they tamponade when you put the trach in.

I've had a few arterial pumpers that caused some serious puckering though.

I typically ultrasound over the sight to make sure there is no midline arterial vessel. There is almost always some nearby venous vessels but seems to not be a big deal.

I've done a bit over 100 since i've been in practice - have not had a serious complication. Pt selection is big in avoiding complications. I think you need to be on really good terms with your ENT colleagues so they can bail you out if needed. Ours are happy to do so because they really didn't like doing the routine trachs in the first place.

 

[VentdependenT]

Id be lying if i said my sphincter tone want high when i saw that drinking fountain of blood. We held pressure for 10min and it stopped. We thought the trach would tamponade bleed and it did. It just sucks doing a procedure that I can get into serious trouble with which would require another physician to bail me out.

Who runs your bronch in private practice?
You have in house ENT to bail you out at your private hospital?

 

[bigtuna]

I get one of my partners to do the bronch - we always have several of us in house during the day.
ENT always within 20 minutes during daylight hours.

Even though there are occasional bleeding complications with perc trachs, I do believe they are less than with surgical ones. Have seen a fair amount of take backs to the OR with surgical trachs. I'll often resume full anticoag within 4-6 hrs of a perc trach with no problem.

 

[Hernandez]

I don't do perc trachs, I only did a few as a fellow, so not enough to be comfortable with, but it makes me pucker to think that people do them blindly without a bronch, yeah yeah I know the literature says it is as safe, but still.

 

[jdh71]

I don't do perc trachs, I only did a few as a fellow, so not enough to be comfortable with, but it makes me pucker to think that people do them blindly without a bronch, yeah yeah I know the literature says it is as safe, but still.

I'm with you and Vent, the surgeons can have them.

 

[Bostonredsox]

I don't do perc trachs, I only did a few as a fellow, so not enough to be comfortable with, but it makes me pucker to think that people do them blindly without a bronch, yeah yeah I know the literature says it is as safe, but still.

I did one blind with a surgeon a few weeks ago. Went quite well. And that was in the face of an lma/bag mask ventilation because I couldn't tube him, I think I actually opened a thread on this.

Anyway, despite it going very well, it's one of 2 perc trachs I've been a part of that were without bronch guidance. Both were emergent. And both were also modified as we did do some sort of a cut down though not a true open trach. In general, the surgeons will only do these bronch guided.

My N is only about 7-8 but haven't had a bleeding problem yet. Though obviously I've had an experienced surgeon assisting me every time.

For my practice as an intensivist, all I really want to be able to do is a an emergent cric. But I have to say the more of these I do the more comfortable I would be doing one in a pinch if an airway goes south, though that is in part because I have only had the ability to do one actual cric. Everyone else had enough time to get a perc trach.

 

[Bostonredsox]

I did one blind with a surgeon a few weeks ago. Went quite well. And that was in the face of an lma/bag mask ventilation because I couldn't tube him, I think I actually opened a thread on this.

Anyway, despite it going very well, it's one of 2 perc trachs I've been a part of that were without bronch guidance. Both were emergent. And both were also modified as we did do some sort of a cut down though not a true open trach. In general, the surgeons will only do these bronch guided.

My N is only about 7-8 but haven't had a bleeding problem yet. Though obviously I've had an experienced surgeon assisting me every time.

For my practice as an intensivist, all I really want to be able to do is a an emergent cric. But I have to say the more of these I do the more comfortable I would be doing one in a pinch if an airway goes south, though that is in part because I have only had the ability to do one actual cric. Everyone else had enough time to get a perc trach.

But as I think most of thepeoplemin this thread are pulm/CC or straight CC except tuna, as long as we can perform some sort of surgical airway when needed in case we happen to be practicing in a place without in house surgeons at night, our bases are covered.

 

[Bostonredsox]

Damn it I meant to edit/add to my post not quote it.

 

[lura]

I do them routinely and me and my partners swap out with one of us doing the bronch, the other the actual trach insertion. My background is in surgery so I'm not as worried about getting into bleeding. As a resident I definately did them blind with some thoracic attendings but I prefer to have the bonus of a bronch to confirm actual placement site and can do a quick BAL if needed at the conclusion. Really shouldn't have too much trouble with bleeders if you watch your initial incision - avoid superficial veins by site. Deeper ones usually do tamponade off.

 

[kazuma]

I assisted ~15 bronch guided blue rhino's and did 6 myself between med school and internship in a private hospital while rotating with the pulm/cc folks. Perhaps we lucked out because I never ran into any significant bleeding. The private pulm/cc guys I rotated with usually had their own nurse that rounded with them (took care of phone calls, scheduling in the outpt clinic etc) who held the bronchoscope if a med student or intern wasn't on the service.

 

[tartesos]

nothing like seeing a vigorous bubbling stream of venous blood pouring out of your perc trach incision to wake you up.

I will NOT be doing these in the community. Gen surg or ENT can have em.

I'm as much of a cowboy as the next guy on procedures, but this one ent and surgeons can have !
As someone said, I just need to know how to do them emerge fly if needed and then I'm done with it!!
Here in town Ent doesn't want to deal with any trach complication that they did not put in...
Ain't nobody got time for that!

 

[Stank811]

The surgeons teach them at my institution in the SICU. Teach them with a bronch and make a 1-2cm skin incision and then blunt dissect down to trachea to avoid big vessels and then perform the "perch trach"….works well and gives you better control I feel.

 

[europeman]

Im a surgeon and intensivist:

I firmly disagree with most of you.

ABSOLUTELY non surgeon Icu docs should be able to do their own perc trachs.

It's just a matter or training. If you use ultrasound to screen for vessels, goiter, high riding innominate, and low riding tracheal rings (all of which you can call Surgey at least initially in your practice) you are well within your scope.

Have u not seen the crazy procedures interventional GI, Pulm, and cards do???!!!!


I think way too many Icu docs limit themselves unnecessarily.

 

[europeman]

One more thing


If you don't regularly do perc trachs..... Please please please don't do one in an emergency. You will surely kill them.

Just learn how to do a surgical cric. It's very easy, and just another procedure. Er docs are often well trained in this and I have witnesses and mentored many do them very very well.

I personally couldn't do a perc trach fast enough in a cant ventilate can't intubate situation and info them all the time.

 

[Hamhock]

europeman (and others) --

It is not the actual procedure that I am not excited about. Rather, the follow-up after discharge from the unit.

I suspect it is difficult to get a general surgeon or ENT or anyone else to follow these patients after they have left the unit -- especially as an outpatient.

And what happens when they come back in to the ED with complications?

Follow-up seems to be a limiting factor for those of us who only practice CCM.

HH

 

[europeman]

Just make relationship with a surgeon for handle the occasional follow up we complication.


As far as out patient follow up. This is very rare anyway. If u do anything else though (Pulm for example) just see them in your clinic.


Otherwise again make a relationship with a surgeon .